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PREVENTING DRUG ABUSE hat do we know? Dean R. Gerstein and Lawrence W. Green, editors Committee on Drug Abuse Prevention Research Commission on Behavioral and Social Sciences and Education National Research Council NATIONAL ACADEMY PRESS Washington, D.C. 1993

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National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This project was sponsored by the National Institute on Drug Abuse. Library of Congress Cataloging-in-Publication Data Preventing drug abuse: what do we know? / Dean R. Gerstein and Lawrence W. Green, editors. p. cm Includes bibliographical references and index. ISBN 0-309-04627-0 1. Drug abuse-United States. 2. Drug abuse-United States Prevention-Evaluation. I. Gerstein, Dean R. II. Green, Lawrence W. HV5825.P74 1993 362.29'17'0973 dc20 Printed in the United States of America Copyright 1993 by the National Academy of Sciences. All rights reserved. 93-7333 CIP

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PREFACE COMMITTEE ON DRUG ABUSE PREVENTION RESEARCH LAWRENCE W. GREEN, Chair, Institute of Health Promotion Research, University of British Columbia BENJAMIN BOWSER, Department of Sociology, California State University at Hayward ERNEST L. CHAVEZ, Department of Psychology, Colorado State University, Fort Collins RICHARD CLAYTON, Center for Prevention Research, University of Kentucky M. JEAN GILBERT, Kaiser-Permanente, Los Angeles MARTIN KOTLER, MACRO International, Inc., Silver Spring, Maryland JOAN MOORE, Department of Sociology, University of Wisconsin, Milwaukee 1~1 PATRICK O'MALLEY, Institute for Social Research, University of Michigan ADRIAN OSTFELD, School of Medicine, Yale University ERIC SCHAPS, Developmental Studies Center, San Ramon, California *RALPH E. TARTER, Department of Psychiatry, University of Pittsburgh School of Medicine *CAROL H. WEISS, Graduate School of Education, Harvard University DEAN R. GERSTEIN, Study Director (National Opinion Research Center, Washington, D.C.) ELAINE MCGARRAUGH, Research Associate MARGARET CARGO, Research Assistant LINDA KEARNEY, Administrative Secretary *Resigned in 1990. . . . 11!

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of dis- tinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Frank Press is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Robert M. White is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communi- ties. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Frank Press and Dr. Robert M. White are chairman and vice chairman, respectively, of the National Research Council.

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Contents PREFACE . . . V11 EXECUTIVE SUMMARY 1 1 ILLICIT DRUG USE IN THE UNITED STATES Diagnosing Drug Problems, 11 Trends in Drug Use, 20 Disaggregation of Special Populations, 32 Summary, 35 References, 37 2 CONCEPTS OF PREVENTION Introduction, 45 Studies of Risk and Vulnerability, 50 The Developmental Approach, 58 Social Influence and Social Learning, 63 Summary, 66 References, 67 3 EVALUATING PREVENTION PROGRAM EFFECTS Meta-Analyses of Prevention Interventions, 78 Three Programs Meeting Tobler's Criteria, 85 Do Large-Scale Social Influence Programs Work?, 90 Research in Progress, 98 Mass Media and Drug Abuse Prevention, 102 Conclusions and Research Needs, 108 References, 112 45 .76 APPENDIX: COMMUNITY SETTINGS AND CHANNELS FOR PREVENTION .................... 1 19 INDEX v .155

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Preface The task of developing scientific knowledge relevant to drug abuse prevention has been a distinct item on the public health research agenda for several decades. The National Institute on Drug Abuse (NIDA), which evolved from a division within the National Institute of Mental Health, has sponsored extramural research on prevention-related topics at the rate of several million dollars annually since the mid-1970s. In the 1980s, other research agencies of the federal government, such as the Centers for Dis- ease Control, the Department of Education, and the Department of Justice, have intensified their interest in this topic. NIDA's sister agency in the Public Health Service, the Center for Substance Abuse Prevention, has obli- gated very substantial sums to a large number of demonstration projects, from which it is hoped that useful evaluation data may be expected. More- over, a number of private foundations and state and local government agen- cies have committed very significant resources to new drug abuse preven- tion activities that entail research or program evaluation components. Tangible progress in prevention research combined with substantially increased interest in prevention program evaluations and demonstration led NIDA to ask the National Research Council for assistance in shaping its own research agenda and providing certain common scientific reference points for others who are interested in the prevention research enterprise. That request led to the formation of the Committee on Drug Abuse Preven- tion Research and to this report of the committee. The charge to the committee was not an open-ended or comprehensive review of the broad front of prevention policies and strategies. Rather, the . . V11

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. . . V111 PREFACE committee followed a research-oriented agenda covering the following spe- cific points of interest to NIDA: Review the current status of drug abuse prevention research: . Assess the theoretical basis for preventive interventions as derived from etiologic research. Identify which drug abuse prevention strategies have been adequately evaluated and found to be effective, not effective, and counter-effective (i.e., those that actually encourage drug abuse). For drug abuse prevention strategies that have been found to be effective, assess how practical are such strategies for use in wide-scale applications and with other population groups (e.g., minorities). Identify which prevention strategies have unknown effectiveness because of inadequate evaluation (e.g., insufficient numbers of replications). Review methodological issues regarding drug abuse prevention strategies: Identify major design and methodology problems in existing pre- vention strategies (i.e., inappropriate control groups, high or nonrandom subject attrition rates, problems with verification or self-report of drug use, contamination by other preventive interventions). . Identify possible approaches for correcting such problems in cur- rent and future prevention research. Identify minimum requirements for assessing effectiveness of pre- vention strategies. NIDA also invited the committee to offer recommendations, as appro- priate, concerning the directions of future research. The charge to the committee specified that it should focus on illicit drug problems. This limitation was not intended to downplay the public health importance of alcohol and tobacco but to assure that maximum guid- ance would be obtained for the central research mission of NIDA. The committee therefore considered research on prevention of alcohol and to- bacco abuse only to the extent that this research is relevant to preventing illicit drug problems. The fact that alcohol and tobacco are generally illicit for minors creates an irreducible overlap in prevention concepts and inter- ventions for young people. We note that a committee at the Institute of Medicine of the National Academy of Sciences has completed a separate study of research needs and opportunities on alcohol problems (Prevention and Treatment of Alcohol Problems: Research Opportunities, Institute of Medicine, 1989), which provided much more comprehensive attention to alcohol abuse prevention as such.

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PREFACE IX In responding to NIDA's request, the National Research Council ap- pointed a committee of research experts from a range of relevant disci- plines, who reviewed the portfolio of current research and considered the lessons to be drawn for each item in the charge. This report, the result of the committee's deliberations, is organized into three chapters, which cover: the nature of the drug problems, particularly in terms of etiologic and epidemiologic data; the conceptual and theoretical foundations of research- based prevention interventions; and the evaluation of prevention programs' effectiveness. The role of community channels and settings for drug abuse prevention seemed to us valuable in illuminating an important direction of research in which an expanded, methodologically sophisticated increment of attention is needed. With the partial exception of research on cigarette smoking, there has not been much attention in drug abuse research to the literature on community health education. We therefore include here an appendix on community strategies of health promotion and disease prevention, empha- sizing the importance of implementation planning in making prevention programs sustainable. We are particularly indebted to two committee members, Patrick O'Malley and Richard Clayton, who took on more than a usual share of the work in drafting the chapters of this report. We would also like to acknowledge the help of Ralph Tarter, who participated in two committee meetings and Carol Weiss, who participated in one; Herbert Kleber and Mary Ann Pentz, who gave stimulating presentations at respective meetings, Zili Amsel and Will- iam Bukoski, the NIDA project officers; and the dedicated panel of anony- mous reviewers appointed by the National Research Council. The committee owes much to the Commission on Behavioral and Social Sciences and Eduation, particularly Eugenia Grohman, associate director of reports, who provided administrative guidance and support; Christine McShane, editor without peer, who groomed the text and brought it through the final stages of preparation; Linda Kearney, administrative coordinator of the study; and Elaine McGarraugh, who served throughout as assistant study direc- tor compiling and organizing research materials, drafting parts of the re- port, and generally ensuring its progress and completion. Margaret Cargo, research assistant at the University of British Columbia, assisted in the final rounds of bibliographic and data compilation. Lawrence W. Green, Chair Dean R. Gerstein, Study Director

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PREVENTING DRUG ABUSE What do we know?

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